REFERRAL PROGRAM AGREEMENT This Agreement is used by

REFERRAL PROGRAM AGREEMENT

This Agreement is used by an agent that will locate, solicit and refer or identify persons or businesses

to the Company who are in need of an Agent or Broker for Property & Casualty (“P&C”) coverage

The undersigned (hereinafter called “Producer”, “You” and “Your”) and Glacier Group, for itself and its

affiliates, meaning those companies now or in the future owned or controlled by or under common control

with Glacier Group and operated collectively as Midwest Insurance Brokerage Services, Inc. and Midwest

Certified Insurance Agency, Ltd. (hereinafter called “Company”, “We”, “Us” and “Our”) agree to the following

provisions:

The Producer shall periodically refer potential customers to Us for its consideration as authorized by Us. The

term “for its consideration” shall mean that all such referrals shall be considered for acceptance and/or

rejection by us before coverage is in effect and the Producer has no right to bind, alter or cancel any coverage

in the absence of specific authorization to do so.

This agreement replaces and supersedes any completed Property & Casualty (“P&C”) Brokerage Agreements

between You and Us.

From time to time, we may change the established procedures and/or referral fee described in this agreement,

and will provide you with notice of any significant change to such procedures or fee(s).

For a referred policy which is effectuated, the Producer will receive a commission payment calculated as

an equivalent of 30% of annual earnings generated for the 1

policy year earned commission generated

by such referral. This will be paid once first year commissions have been received by our Agency from

Carrier.

For in force referred policies which renew into their 2

policy year, the Producer will receive renewal

commissions as an equivalent of 30% of annual earnings generated by referral. This will be paid once

year two renewal commissions have been received by our Agency from Carrier.

Producer will not receive renewal commissions on in force referral policies which renew into their 3

policy year or any subsequent policy years.

To be eligible for commission, Producer must maintain an active producer license, must provide a completed

W-9 form and must identify Referred Customer directly to Us by email, fax or hand delivery of such document.

Producer will report promptly to Us all changes in address and relevant license information.

All fees, commission and other charges must be fully disclosed to the insureds by the Broker if required by law.

The Producer agrees to refund commissions or other charges on policy cancellations or reductions at the same

rate at which such commission or other charges were originally paid.

Such commission as is agreed upon shall be the maximum commission.

We will not sell, solicit, negotiate or pursue other lines of coverage within your expertise without your direct

written consent.

We will be the Property & Casualty agent of record for all insured’s referred. The Producer and any Sub-

Producer of the Producer, is an independent contractor, not an employee of the Company.

We will defend and indemnify You against liability, including costs of defense and settlements, imposed on You

by law for damages sustained and caused solely by Our acts and omissions related to this Agreement, provided

You have not caused or contributed to such liability by Your own acts or omissions. You agree to defend and

indemnify Us against liability to the extent You would be liable under common omissions in violation of the

terms of this Agreement.

Either Party may terminate this Agreement at any time and without liability by providing a (10) day advance

written notice to the other unless otherwise agreed to in writing or required by state law. Upon termination

of this Agreement, We shall continue as the Agent of Record.

This with the understanding of the parties to this Agreement, Producer is an independent contractor and not

an employee, partner or consultant and will comply with all laws relating to business performed under this

Agreement.

Producer Name:____________________________________________SS#:_________________________________

Agency Name:_____________________________________________ Tax ID#:______________________________

Address:__________________________________________________ Phone:______________________________

__________________________________________________ Fax:_________________________________

Email:_____________________________________________________

Effective the _______________________day of__________________________________, 20_______

Agency Name: ______________________________________________________________________

Principal/Owner Name:__________________________Signature:_____________________________

Broker Printed Name: ___________________________Signature:_____________________________

Agency Name: Glacier Group for itself, and its affiliate

Representative Name: ___________________________Signature: ____________________________

Referral Form Property & Casualty

Date:_______________________________________ NPN Producer No:________________

Referring Agent/Agency Name:__________________________________________________________________

Contact No.:____________________________________________Email:______________________________________

Customer Information

Name of Contact(s):__________________________________________________________________________________

Business Name (if applicable):______________________________________________________________________

Address:_______________________________________________________________________________________________

_____________________________________________________Website:__________________________________________

Contact No:________________________________________Email:____________________________________________

Desired Line(s) of Coverage

 Personal Lines Line(s) of Coverage:___________________________________________________

 Commercial Lines Line(s) of Coverage:___________________________________________________

Notes – What else can you tell us?

Suggestions: Date of Birth/Description of Operations/Sales/No. of EE’s/Payroll/Problems or

Concerns

_________________________________________________________________________________________________________

Once completed you can Email this form along with declaration pages and any other

correspondence to commercial@midwestga.com, personal@midwestga.com or fax to

847-640-8011.

This form is for those agents/agencies with a Referral Agreement in place. Agent

must have an insurance license in order to receive commission and/or referral

fee.

Thank you for your continued confidence in our agency!

Additional Notes